Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
IDENTIFICATION SECTION Company
Name and Address of Insurance
Name of Insurance Company must be inserted before this form is used. Use the actual
name of the company. Do not use group names.
FORM PURPOSE
Formal Application, Informal
Inquiry, Change or Other
Check the appropriate box or write in Other to indicate.
FORM PURPOSE
Case ID
Insert the identification number that identifies the case in the agency system.
FORM PURPOSE
Policy Number (For Changes Only)
Number exactly as it appears on the policy, including prefix and suffix symbols.
PRIMARY PRODUCER
First Name
First name of the producer.
PRIMARY PRODUCER
Middle Name
Middle name of the producer.
PRIMARY PRODUCER
Last Name
Last name of the producer.
PRIMARY PRODUCER
Producer Number
The identification number of the Producer.
PRIMARY PRODUCER
BGA Name (If Applicable)
The name of the Brokerage General Agency (BGA).
INSURANCE APPLIED FOR Plan Name
Insert the name of the plan.
INSURANCE APPLIED FOR Term Plan
Indicate the type of Term Plan.
INSURANCE APPLIED FOR Class Applied For
Insert the class applied for.
INSURANCE APPLIED FOR Initial Insurance Amount
Insert the initial insurance amount.
INSURANCE APPLIED FOR Life Policies Only)
Death Benefit Option (Universal
Indicate the Death Benefit Option for Universal Life Policies.
INSURANCE APPLIED FOR Dividend Options (If Applicable)
Indicate the Dividend Options, if applicable.
INSURANCE APPLIED FOR Applicable to the Selected Plan)
Supplemental Coverage (If
Indicate the Supplemental Coverage option, if applicable to the selected plan.
INSURANCE APPLIED FOR Purpose of Insurance
Indicate the purpose of this insurance.
PROPOSED INSURED (PI)
Additional Other Proposed Insured
Supplement Attached
Check this box if the Additional Other Proposed Insured Supplement is attached.
ACORD 701 ME (2003/09)
1 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
PROPOSED INSURED (PI)
First Name
First name of the proposed insured.
PROPOSED INSURED (PI)
Middle Name
Middle name of the proposed insured.
PROPOSED INSURED (PI)
Last Name
Last name of the proposed insured.
PROPOSED INSURED (PI)
Legal Residence (No P.O. Box)
Line 1
Indicate the legal residence of the proposed insured. Do not use P.O. Box number.
Check if this address is the preferred method of mailing.
PROPOSED INSURED (PI)
Line 2
Residence address - Line 2.
PROPOSED INSURED (PI)
City
Indicate the city of the address.
PROPOSED INSURED (PI)
State
State of the address.
PROPOSED INSURED (PI)
Zip
Zip code, postal code, etc. (country dependent)
PROPOSED INSURED (PI)
Country
Indicate the country of the address.
PROPOSED INSURED (PI)
e-mail Address
The e-mail address of the proposed insured.
PROPOSED INSURED (PI)
Years at Current Address
Indicate years at current address.
PROPOSED INSURED (PI)
Date of Birth
Indicate the date of birth of the proposed insured in MM/DD/YYYY format.
PROPOSED INSURED (PI)
Birth State / Province
Indicate the birth state or province of the proposed insured.
PROPOSED INSURED (PI)
Birth Country
Indicate the birth country of the proposed insured.
PROPOSED INSURED (PI)
Male or Female
Indicate whether the proposed insured is male or female.
PROPOSED INSURED (PI)
Height '
Indicate the height of the proposed insured in feet and inches.
PROPOSED INSURED (PI)
Weight_______lbs.
Indicate the weight of the proposed insured.
PROPOSED INSURED (PI)
Maiden Last Name
Indicate the maiden last name of the proposed insured.
PROPOSED INSURED (PI)
Marital Status
Indicate the marital status of the proposed insured.
PROPOSED INSURED (PI)
SSN # / Gov't ID
Social security number or Government Identification Number of proposed insured.
PROPOSED INSURED (PI)
Driver's License #
Indicate the proposed insured's driver's license number.
PROPOSED INSURED (PI)
Drivers Lic State
Indicate the state that issued the proposed insured's driver's license.
PROPOSED INSURED (PI)
Are you a citizen of the United
States? Yes No
Check the appropriate box to indicate whether or not you are a U.S. Citizen. If no,
indicate your country of citizenship, your visa type and your date of arrival in the U.S.
PROPOSED INSURED (PI)
Home Phone
Indicate the home phone number of the proposed insured, including area code.
PROPOSED INSURED (PI)
Best Time To Call or Date
Indicate the best time or date (MM/DD/YYYY) to call the proposed insured.
PROPOSED INSURED (PI)
Work Phone
Indicate the work phone number of the proposed insured, including area code.
PROPOSED INSURED (PI)
Best Time To Call or Date
Indicate the best time or date (MM/DD/YYYY) to call the proposed insured.
PROPOSED INSURED (PI)
Employer Name
The name of the Employer.
ACORD 701 ME (2003/09)
2 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
PROPOSED INSURED (PI)
Employer Address Line 1
Indicate the employer address of the proposed insured.
PROPOSED INSURED (PI)
Line 2
Employer Address Line 2
PROPOSED INSURED (PI)
City
Indicate the city of the address.
PROPOSED INSURED (PI)
State
State of the address.
PROPOSED INSURED (PI)
Zip
Zip code, postal code, etc. (country dependent)
PROPOSED INSURED (PI)
Country
Indicate the country of the address.
PROPOSED INSURED (PI)
Years with Current Employer
Indicate years with current employer.
PROPOSED INSURED (PI)
Annual Income_______$
Indicate the annual income of the proposed insured.
PROPOSED INSURED (PI)
Net Worth_______$
Indicate the net worth of the proposed insured.
PROPOSED INSURED (PI)
Occupation (Include Duties)
Describe the occupation of the proposed insured, including duties.
OTHER PROPOSED
INSURED (OTHER PI)
Joint or Rider
Indicate whether Joint or Rider (If Applicable to the Plan Applied For)
OTHER PROPOSED
INSURED (OTHER PI)
Last Name
Last name of the proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Legal Residence (No P.O. Box)
Line 1
Indicate the legal residence of the proposed insured. Do not use P.O. Box number.
Check if this address is the preferred method of mailing.
OTHER PROPOSED
INSURED (OTHER PI)
Line 2
Residence address - Line 2.
OTHER PROPOSED
INSURED (OTHER PI)
City
Indicate the city of the address.
OTHER PROPOSED
INSURED (OTHER PI)
State
State of the address.
OTHER PROPOSED
INSURED (OTHER PI)
Zip
Zip code, postal code, etc. (country dependent)
OTHER PROPOSED
INSURED (OTHER PI)
Country
Indicate the country of the address.
OTHER PROPOSED
INSURED (OTHER PI)
e-mail Address
The e-mail address of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Years at Current Address
Indicate years at current address.
ACORD 701 ME (2003/09)
3 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
OTHER PROPOSED
INSURED (OTHER PI)
Date of Birth
Indicate the date of birth of the other proposed insured in MM/DD/YYYY format.
OTHER PROPOSED
INSURED (OTHER PI)
Birth State / Province
Indicate the birth state or province of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Birth Country
Indicate the birth country of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Male or Female
Indicate whether the other proposed insured is male or female.
OTHER PROPOSED
INSURED (OTHER PI)
Height '
Indicate the height of the other proposed insured in feet and inches.
OTHER PROPOSED
INSURED (OTHER PI)
Weight_______lbs.
Indicate the weight of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Maiden Last Name
Indicate the maiden last name of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Marital Status
Indicate the marital status of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
SSN # / Gov't ID
Social security number or Government Identification Number of other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Driver's License #
Indicate the other proposed insured's driver's license number.
OTHER PROPOSED
INSURED (OTHER PI)
Drivers Lic State
Indicate the state that issued the other proposed insured's driver's license.
OTHER PROPOSED
INSURED (OTHER PI)
Are you a citizen of the United
States? Yes No
Check the appropriate box to indicate whether or not you are a U.S. Citizen. If no,
indicate your country of citizenship, your visa type and your date of arrival in the U.S.
OTHER PROPOSED
INSURED (OTHER PI)
Home Phone
Indicate the home phone number of the other proposed insured, including area code.
OTHER PROPOSED
INSURED (OTHER PI)
Best Time To Call or Date
Indicate the best time or date (MM/DD/YYYY) to call the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Work Phone
Indicate the work phone number of the other proposed insured, including area code.
ACORD 701 ME (2003/09)
4 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
OTHER PROPOSED
INSURED (OTHER PI)
Best Time To Call or Date
Indicate the best time or date (MM/DD/YYYY) to call the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Employer Name
The name of the Employer.
OTHER PROPOSED
INSURED (OTHER PI)
Employer Address Line 1
Indicate the address of the other proposed insured's employer.
OTHER PROPOSED
INSURED (OTHER PI)
Line 2
Employer Address Line 2
OTHER PROPOSED
INSURED (OTHER PI)
City
Indicate the city of the address.
OTHER PROPOSED
INSURED (OTHER PI)
State
State of the address.
OTHER PROPOSED
INSURED (OTHER PI)
Zip
Zip code, postal code, etc. (country dependent)
OTHER PROPOSED
INSURED (OTHER PI)
Country
Indicate the country of the address.
OTHER PROPOSED
INSURED (OTHER PI)
Years with Current Employer
Indicate years with current employer.
OTHER PROPOSED
INSURED (OTHER PI)
Annual Income_______$
Indicate the annual income of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Net Worth_______$
Indicate the net worth of the other proposed insured.
OTHER PROPOSED
INSURED (OTHER PI)
Occupation (Include Duties)
Describe the occupation of the other proposed insured, including duties.
OWNER
Complete only if Owner is to be other than Proposed Insured.
OWNER
Type of Owner
Check the appropriate box to indicate type of owner.
OWNER
Name of Trustee
Indicate the name of the Trustee.
OWNER
Date of Trust Agreement
Indicate the date of the Trust Agreement. (MM/DD/YYYY)
OWNER
First Name
First name of the owner.
OWNER
Middle Name
Middle name of the owner.
OWNER
Last Name
Last name of the owner.
ACORD 701 ME (2003/09)
5 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
OWNER
Address (No P.O. Box) Line 1
Indicate the address of the owner. Do not use P.O. Box number. Check if this address is
the preferred method of mailing.
OWNER
Line 2
Address - Line 2.
OWNER
City
Indicate the city of the address.
OWNER
State
State of the address.
OWNER
Zip
Zip code, postal code, etc. (country dependent)
OWNER
Country
Indicate the country of the address.
OWNER
Date of Birth
Indicate the date of birth of the producer in MM/DD/YYYY format.
OWNER
SSN # / FEIN #
Social security number or Federal Employment Identification Number of the owner.
OWNER
Relation To Proposed Insured
Indicate the relation to the proposed insured.
OWNER
Full Name
If other than individual, give full name of the owner.
OWNER
Are you a citizen of the United
States? Yes or No
Check the appropriate box to indicate whether or not you are a U.S. Citizen. If no,
indicate your country of citizenship.
OTHER OWNER
Joint Owner or Contingent Owner
Indicate whether Joint Owner or Contingent Owner.
OTHER OWNER
Type of Owner
Check the appropriate box to indicate type of owner.
OTHER OWNER
Name of Trustee
Indicate the name of the Trustee.
OTHER OWNER
Date of Trust Agreement
Indicate the date of the Trust Agreement. (MM/DD/YYYY)
OTHER OWNER
First Name
First name of the owner.
OTHER OWNER
Middle Name
Middle name of the owner.
OTHER OWNER
Last Name
Last name of the owner.
OTHER OWNER
Address (No P.O. Box) Line 1
Indicate the address of the owner. Do not use P.O. Box number. Check if this address is
the preferred method of mailing.
OTHER OWNER
Line 2
Address - Line 2.
OTHER OWNER
City
Indicate the city of the address.
OTHER OWNER
State
State of the address.
OTHER OWNER
Zip
Zip code, postal code, etc. (country dependent)
OTHER OWNER
Country
Indicate the country of the address.
OTHER OWNER
Date of Birth
Indicate the date of birth of the producer in MM/DD/YYYY format.
OTHER OWNER
SSN # / FEIN #
Social Security Number or Federal Employment Identification Number of the owner.
OTHER OWNER
Relation To Proposed Insured
Indicate the relation to the proposed insured.
ACORD 701 ME (2003/09)
6 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
OTHER OWNER
Full Name
If other than individual, give full name of the owner.
OTHER OWNER
Are you a citizen of the United
States? Yes or No
Check the appropriate box to indicate whether or not you are a U.S. Citizen. If no,
indicate your country of citizenship.
PRIMARY BENEFICIARY
Irrevocable? Yes or No
Check the appropriate box to indicate whether or not the beneficiary is irrevocable.
PRIMARY BENEFICIARY
Notice: Unless you specify otherwise, payments will be shared equally by all primary
beneficiaries who survive the Proposed Insured(s) or, if none, by all contingent
beneficiaries who survive the Proposed Insured(s). The right to change the beneficiary is
reserved to the Owner unless otherwise stated. * Default is No if neither box is checked.
PRIMARY BENEFICIARY
First Name
First name of the beneficiary.
PRIMARY BENEFICIARY
Middle Name
Middle name of the beneficiary.
PRIMARY BENEFICIARY
Last Name
Last name of the beneficiary.
PRIMARY BENEFICIARY
Name of Trustee
Indicate the name of the Trustee.
PRIMARY BENEFICIARY
Date of Trust Agreement
Indicate the date of the Trust Agreement. (MM/DD/YYYY)
PRIMARY BENEFICIARY
Full Name
If other than individual, give full name of the beneficiary.
PRIMARY BENEFICIARY
Address (No P.O. Box) Line 1
Indicate the address of the beneficiary. Do not use P.O. Box number. Check if this
address is the preferred method of mailing.
PRIMARY BENEFICIARY
Line 2
Address - Line 2.
PRIMARY BENEFICIARY
City
Indicate the city of the address.
PRIMARY BENEFICIARY
State
State of the address.
PRIMARY BENEFICIARY
Zip
Zip code, postal code, etc. (country dependent)
PRIMARY BENEFICIARY
Country
Indicate the country of the address.
PRIMARY BENEFICIARY
Date of Birth
Indicate the date of birth of the producer in MM/DD/YYYY format.
PRIMARY BENEFICIARY
SSN # / TIN #
Social Security Number or Tax Identification Number of the beneficiary.
PRIMARY BENEFICIARY
Relation To Proposed Insured
Indicate the relation to the proposed insured.
PRIMARY BENEFICIARY
% Share
Indicate percentage of distribution for beneficiary.
ADDITIONAL BENEFICIARY Irrevocable? Yes or No
Check the appropriate box to indicate whether or not the beneficiary is irrevocable.
ADDITIONAL BENEFICIARY Primary, Contingent or Other
Check the appropriate box to indicate whether or not the beneficiary is primary, contingent
or other. (Explain other in remarks section).
ACORD 701 ME (2003/09)
7 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
ADDITIONAL BENEFICIARY First Name
First name of the beneficiary.
ADDITIONAL BENEFICIARY Middle Name
Middle name of the beneficiary.
ADDITIONAL BENEFICIARY Last Name
Last name of the beneficiary.
ADDITIONAL BENEFICIARY Name of Trustee
Indicate the name of the Trustee.
ADDITIONAL BENEFICIARY Date of Trust Agreement
Indicate the date of the Trust Agreement. (MM/DD/YYYY)
ADDITIONAL BENEFICIARY Full Name
If other than individual, give full name of the beneficiary.
ADDITIONAL BENEFICIARY Address (No P.O. Box) Line 1
Indicate the address of the beneficiary. Do not use P.O. Box number. Check if this
address is the preferred method of mailing.
ADDITIONAL BENEFICIARY Line 2
Address - Line 2.
ADDITIONAL BENEFICIARY City
Indicate the city of the address.
ADDITIONAL BENEFICIARY State
State of the address.
ADDITIONAL BENEFICIARY Zip
Zip code, postal code, etc. (country dependent)
ADDITIONAL BENEFICIARY Country
Indicate the country of the address.
ADDITIONAL BENEFICIARY Date of Birth
Indicate the date of birth of the producer in MM/DD/YYYY format.
ADDITIONAL BENEFICIARY SSN # / TIN #
Social Security Number or Tax Identification Number of the beneficiary.
ADDITIONAL BENEFICIARY Relation To Proposed Insured
Indicate the relation to the proposed insured.
ACORD 701 ME (2003/09)
8 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
ADDITIONAL BENEFICIARY % Share
Indicate percentage of distribution for beneficiary.
OTHER INSURANCE
Check either YES or NO to the questions regarding other insurance. If you answer
YES please complete table.
OTHER INSURANCE
Table for Proposed or Other
Proposed Insured
OTHER INSURANCE
Name of Insurance Company
Use the actual name of the company. Do not use group names.
OTHER INSURANCE
Policy #
Number exactly as it appears on the policy, including prefix and suffix symbols.
OTHER INSURANCE
Amount
Indicate the amount of the insurance.
OTHER INSURANCE
Issue Year
Indicate the year the insurance was issued.
OTHER INSURANCE
Policy Type - Life or Annuity
Indicate whether the policy type is Life or Annuity.
OTHER INSURANCE
Individual or Group
Indicate whether the insurance is Individual or Group.
OTHER INSURANCE
Purpose - Business or Personal
Indicate whether the purpose of insurance is for business or personal.
OTHER INSURANCE
Pending - Yes or No
Indicate whether the insured has pending insurance.
OTHER INSURANCE
Replace - Yes or No
Indicate whether the insured has replaced insurance.
OTHER INSURANCE
1035 Exchange - Yes or No
Indicate whether the insured has a 1035 Exchange.
PAYMENT PLAN
Premium Mode
Check the appropriate box to indicate the premium mode.
PAYMENT PLAN
Payment Method
Check the appropriate box to indicate the method of payment.
PAYMENT PLAN
Billing
Check the appropriate box to indicate the billing method.
PAYMENT PLAN
Premium Quoted
Indicate the premium quoted
PAYMENT PLAN
Premium Included with Application
- Yes or No
Indicate whether or not premium is included with application. If Yes, indicate amount.
PAYMENT PLAN
Automatic Premium Loan - Yes or
No
Indicate whether or not there was an automatic premium loan.
PAYMENT PLAN
Payor Name
The name of the payor.
PAYMENT PLAN
Payor Address Line 1
Indicate the address of the payor.
PAYMENT PLAN
Line 2
Payor Address Line 2
PAYMENT PLAN
City
Indicate the city of the address.
PAYMENT PLAN
State
State of the address.
PAYMENT PLAN
Zip
Zip code, postal code, etc. (country dependent)
PAYMENT PLAN
Country
Indicate the country of the address.
ACORD 701 ME (2003/09)
9 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
PAYMENT PLAN
SSN # / TIN #
Social Security Number or Tax Identification Number of the payor.
GENERAL INFORMATION
For Proposed Insured (PI) or Other
Proposed Insured (Other PI)
NOTICE: Insurance cannot take effect and premium cannot be collected with the
application if any of questions 10.j through 10.l in the General Information Section are
answered Yes or not answered. Check either YES or NO to the General Information
questions and indicate whether for Proposed Insured or Other Proposed Insured. If you
answer YES to any of these questions, explain in Remarks section on pages 5 & 6.
GENERAL INFORMATION
a) Has any proposed insured ever
applied for Life or Disability
insurance and been turned down?
GENERAL INFORMATION
b) With respect to insurance
previously applied for, does/has
any proposed insured: 1) Have an
application, informal inquiry or
reinstatement request for Life or
Disability insurance pending with
any other company or society? 2)
Ever been asked to pay a higher
premium? 3) Ever been issued a
reduced face amount? 4)
Withdrawn any application or
informal inquiry?
GENERAL INFORMATION
c) Has any proposed insured ever
used or is currently using tobacco
or any other product that contains
nicotine? If yes, provide details.
If you answer YES, please complete table.
ACORD 701 ME (2003/09)
10 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
GENERAL INFORMATION
d) In the past ten (10) years has
any proposed insured requested
or received Workers'
Compensation, Social
Security Disability or other
Disability payments, excluding
pregnancy related payments?
GENERAL INFORMATION
e) Has any proposed insured ever
been convicted of a felony?
GENERAL INFORMATION
f) Within the past five (5) years
has any proposed insured: 1) Had
his or her driver's license
suspended or revoked? 2) Been
convicted of three (3) or more
moving violations? 3) Been
convicted of reckless driving or
driving under the influence of
alcohol or drugs?
GENERAL INFORMATION
g) Within the past five (5) years
has any proposed insured
operated or had any duties aboard
an aircraft, glider,
hot air balloon, ultralight or similar
device; or within the next two (2)
years does he/she plan to operate
or have any duties?
If yes, complete supplement. Contact your insurance carrier to provide the appropriate
supplement.
ACORD 701 ME (2003/09)
11 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
GENERAL INFORMATION
h) Within the past five (5) years
has any proposed insured
engaged in; or within the next two
(2) years does any
proposed insured expect to
engage in: parachuting; hang
gliding; cave exploration; rodeo
riding; mountain, rock or ice
climbing; motor vehicle,
motorcycle, snowmobile or boat
racing; or SCUBA/sky diving?
If yes, complete supplement. Contact your insurance carrier to provide the appropriate
supplement.
GENERAL INFORMATION
i) Within the next two (2) years,
does any proposed insured plan to
travel or reside outside of the
United States?
GENERAL INFORMATION
j) Within the past 90 days, has any
proposed insured been admitted
to a hospital or other medical
facility, been
advised to be admitted, had
surgery performed or
recommended or been advised to
have a diagnostic test
other than an HIV (Human
Immunodeficiency Virus) test?
Answer this question NO if you have tested positive for HIV but have not developed
symptoms of the disease AIDS/ARC.
ACORD 701 ME (2003/09)
12 of 14
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
GENERAL INFORMATION
k) Has any proposed insured ever
used cocaine or any other
controlled substances (other than
as prescribed by a physician) or
has any proposed insured been
counseled, treated or hospitalized
for drug use?
GENERAL INFORMATION
l) Within the past ten (10) years,
has any proposed insured had or
been treated for heart disorder,
heart disease, angina, stroke,
hypertension, high blood
pressure, diabetes or cancer?
REMARKS
Use this space for any additional remarks.
SIGNATURE
City and State
Indicate the city and state where the application was signed.
SIGNATURE
Policy Delivery State
Indicate the state where the policy will be delivered. (If different from state where
application was signed)
SIGNATURE
Signature of Proposed Insured
Proposed Insured must sign the form.
SIGNATURE
Date
Date proposed insured signed the form.
SIGNATURE
Signature of Proposed Insured /
Owner / Applicant
Proposed Insured, Owner (if other than Proposed Insured) or Applicant (if other than
Proposed Insured) must sign the form, if applicable. Check the appropriate box.
SIGNATURE
Date
Date Proposed Insured, Owner (if other than Proposed Insured) or Applicant (if other than
Proposed Insured), if applicable, signed the form.
PRODUCER STATEMENT
Check either YES or NO to the questions regarding other insurance.
PRODUCER STATEMENT
Application Translated
Indicate whether application was translated.
PRODUCER STATEMENT
Name of Translator
Indicate the name of translator.
PRODUCER STATEMENT
Producer Name
Indicate the business name of the producer.
PRODUCER STATEMENT
State License Identification
Number
Indicate the producers state license identification number.
ACORD 701 ME (2003/09)
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 701 ME (2003/09)
Maine Life Insurance Application -
Part 1
ACORD Maine Life Insurance Application - Part 1 (ACORD 701 ME), is a standard life
application accepted by multiple carriers, not all features and benefits offered on this
application are available with each carrier's life insurance plans. Be sure to contact your
agent or the underwriting carrier to verify the specific benefits available in the plan for
which the proposed insured is applying.
PRODUCER STATEMENT
Signature of Producer
Producer must sign the form.
PRODUCER STATEMENT
Date
Date producer signed the form.
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